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The hip is one of the body’s largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).
The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.
A thin tissue called the synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.
Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to the joint.
Normal hip anatomy.
The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.
In hip osteoarthritis, the smooth articular cartilage wears away and becomes frayed and rough.
In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components.
(Left) The individual components of a total hip replacement. (Center) The components merged into an implant. (Right) The implant as it fits into the hip.
The decision to have hip replacement surgery should be a cooperative one made by you, your family, your primary care doctor, and your orthopaedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopaedic surgeon for an initial evaluation.
There are several reasons why your doctor may recommend hip replacement surgery. People who benefit from hip replacement surgery often have:
There are no absolute age or weight restrictions for total hip replacements.
Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total hip replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.
An evaluation with an orthopaedic surgeon consists of several components.
(Left) In this x-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space.
Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options — such as medications, physical therapy, or other types of surgery — also may be considered.
In addition, your orthopaedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery.
Never hesitate to ask your doctor questions when you do not understand. The more you know, the better you will be able to manage the changes that hip replacement surgery will make in your life.
An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do. Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.
With normal use and activity, the material between the head and the socket of every hip replacement implant begins to wear. Excessive activity or being overweight may speed up this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports.
Realistic activities following total hip replacement include unlimited walking, swimming, golf, driving, hiking, biking, dancing, and other low-impact sports.
With appropriate activity modification, hip replacements can last for many years.
If you decide to have hip replacement surgery, your orthopaedic surgeon may ask you to have a complete physical examination by your primary care doctor before your surgical procedure. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such a cardiologist, before the surgery.
Several tests, such as blood and urine samples, an electrocardiogram (EKG), and chest x-rays, may be needed to help plan your surgery.
Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for treatment to improve your skin before surgery.
If you are overweight, your doctor may ask you to lose some weight before surgery to minimize the stress on your new hip and possibly decrease the risks of surgery.
Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal work) should be completed before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.
Individuals with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before having surgery.
Although you will be able to walk with a cane, crutches or a walker soon after surgery, you may need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry.
If you live alone, a social worker or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended care facility during your recovery after surgery also may be arranged.
Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:
You will either be admitted to the hospital on the day of your surgery or you will go home the same day. The plan to either be admitted or to go home should be discussed with your surgeon prior to your operation.
Upon arrival at the hospital or surgery center, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.
Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic, ceramic, or metal, which may have an outer metal shell).
The prosthetic components may be “press fit” into the bone to allow your bone to grow onto the components or they may be cemented into place. The decision to press fit or to cement the components is based on several factors, such as the quality and strength of your bone. A combination of a cemented stem and a non-cemented socket may also be used.
Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.
(Left) A standard non-cemented femoral component. (Center) A close-up of this component showing the porous surface for bone ingrowth. (Right) The femoral component and the acetabular component working together.
(Left) The acetabular component shows the plastic (polyethylene) liner inside the metal shell. (Right) The porous surface of this acetabular component allows for bone ingrowth. The holes around the cup are used if screws are needed to hold the cup in place.
The surgical procedure usually takes from 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position new metal, plastic, or ceramic implants to restore the alignment and function of your hip.
X-rays before and after total hip replacement. In this case, non-cemented components were used.
The success of your surgery will depend in large measure on how well you follow your orthopaedic surgeon’s instructions regarding home care during the first few weeks after surgery.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that, although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose have become critical public health issues in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
You may have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed approximately 2 weeks after surgery.
Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.
Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.
Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within 3 to 6 weeks following surgery. Some discomfort with activity and at night is common for several weeks.
Your activity program should include:
The complication rate following hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit full recovery.
Infection may occur superficially in the wound or deep around the prosthesis. It may happen within days or weeks of surgery. It may even occur years later.
Minor infections of the wound are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Blood clots in the leg veins or pelvis are one of the most common complications of hip replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program which may include blood thinning medications, support hose, inflatable leg coverings, ankle pump exercises, and early mobilization.
Sometimes after a hip replacement, one leg may feel longer or shorter than the other. Your orthopaedic surgeon will make every effort to make your leg lengths even, but may lengthen or shorten your leg slightly in order to maximize the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe lift after surgery.
Over years, the hip prosthesis may wear out or loosen. This is most often due to everyday activity. It can also result from a biologic thinning of the bone called osteolysis. If loosening is painful, a second surgery called a revision may be necessary.
Nerve and blood vessel injury, bleeding, fracture, and stiffness can occur. A small number of patients continue to experience pain after surgery.
Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.
Warning signs of blood clots. The warning signs of possible blood clot in your leg include:
Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:
A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections.
Following surgery, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter your bloodstream. Your orthopaedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.
Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible hip replacement infection:
A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, or handrails or have someone help you until you improve your balance, flexibility, and strength.
Your orthopaedic surgeon and physical therapist will help you decide which assistive aides will be required following surgery, and when those aides can safely be discontinued.
To assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping — usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement.
Your surgeon and physical therapist will provide you with any specific precautions you should follow.
You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery.
Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated.
There are many things you can do to protect your hip replacement and extend the life of your hip implant.
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